چند مورد رو بالا با هم مرور کردیم.
خب مبحث شایعی که بصورت کلی به دو بخش life-threatening و nonlife-threatening تقسیم شده.
یه نکته مهم افتراق هموپتزی از هماتمز هست که گاها ممکنه بیمار خیلی درست شرح حال نده، چیزی که کمکمون میکنه شرح حال دقیق تر براساس مورد پایینه؛
If the bleeding is after nausea/vomiting it is possibly hematemesis;
if it is after recurrent cough, it is possibly hemoptysis.
مورد دیگه که بازم حواسمون به جناب PTE باشه اینجا هم😬 و ریسک فاکتورهای malignancy.
"Life-threatening hemoptysis" refers to hemoptysis that results in significant airway obstruction, abnormal gas exchange, or hemodynamic instability. Approximate volumes of blood associated with life-threatening hemoptysis: 150 mL (about half a cup) in 24 hours or a bleeding rate of 100 mL/hour.
Common causes: Bronchiectasis (includes cystic fibrosis), bronchogenic neoplasms, tuberculosis, fungal infections (eg, aspergilloma)*.
📝 ED order for life-threatening hemoptysis
#Order
▪️Imp : life-threatening hemoptysis
▪️Cond: emergency
▪️Diet : NPO
▪️Act: CBR
▪️Pos : position patient with bleeding side down if possible.
* Some advocate for prone positioning
▪️C.V.S
▪️IV line fix 2 large bore
▪️IV fluid therapy for hypotension
* 1L N.S IV stat
▪️CM and POM
▪️Tracheal intubation and mechanical ventilation as necessary
* Indicated for patients with impending or actual acute respiratory failure, hemodynamic instability, depressed mental status, or need for airway protection
▪️supplemental oxygen to maintain sat between 88-96%
*Patients with lifethreatening hemoptysis are not typically candidates for noninvasive ventilation (NIV), especially with a full-face mask since the risk of aspirating blood is high. If patients refuse or do not need ventilation, then low or high flow nasal oxygen or NIV via a nasal mask or prongs are options.
▪️ECG stat (pulmonary hypertension/PE)
▪️measure or quantitate hemoptysis
▪️check Complete blood count, differential, INR, PTT, routine chemistries, type and cross match, D-dimer, sputum bacterial and mycobacterial stains and culture, VBG, U/A, LTF
▪️appropriate position
* If the side of bleeding is known, position patient with bleeding side down (eg, right lateral decubitus for right lung bleeding).
▪️Chest CT with and w/o IV contrast if patient was stable
*CXR if unstable
▪️Flexible bronchoscopy
*Expertise required. Can be performed bedside in an unstable patient. Bronchoscopy is helpful diagnostically and can be combined with local therapies to temporize the bleeding (eg, iced saline, local vasoconstrictors, bronchial blocker/balloon).
*Ideally, both bronchoscopy
and chest computed tomography (CT) are performed within the first 12 to 24 hours
▪️Consider Reverse bleeding disorders, if possible:
*Fresh frozen plasma to reverse warfarin
*Specific reversal agent for DOACs
*Platelet transfusion for plt <50 or for platelet defects due to uremia or antiplatelet agents (eg, aspirin, clopidogrel)
*Desmopressin for platelet dysfunction for uremia or aspirin use
▪️Consider supportive therapy
▫️Antibiotics: Antibiotic therapy for patients with acute bronchitis, pneumonia, or exacerbations of bronchiectasis.
▫️Bronchodilators: Inhaled bronchodilator therapy for patients with COPD or asthma.
▫️Vasopressors: Vasopressors for hypotension that is refractory to volume resuscitation.
▫️Experimental therapy: Inhaled recombinant factor VIIa (off-label tranexamic acid is generally, only used if other initial therapies have failed).
▫️Transfusion of packed red cells: Rarely required.
▪️Surgical consultation
*Assess possible need for urgent surgery (eg, hemoptysis that is due to trauma, iatrogenic rupture of the pulmonary artery, tracheoinnominate artery fistula).
▪️Interventional radiology consultation
*Consider possible pulmonary angiogram and embolization in patients with ongoing active bleeding (eg, hemoptysis due to AVMs, bronchiectasis, cavitary lesions).
▪️Anesthesia consultation( icu admission + need for intubation)
* All patients with life-threatening hemoptysis should be admitted to the ICU